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Why Does a Shoulder Pulley Help in Recovery?

Shelby Green, PT, DPT, MTC, CLT-LANA

What is a Pulley?

A shoulder pulley is a commonly used device in the rehab setting to aid in recovery from a shoulder injury or surgery. The pulley itself is a very simple device, which involves a door attachment and a handled rope that attaches to the pulley system. Due to the simplicity of this device, it has been found to be a great tool to use at home as part of a home exercise program; however, the real question remains: why does a shoulder pulley help in recovery?

Shoulder Dysfunctions

To understand why a pulley will assist in the rehab process, it is helpful to know what type of shoulder conditions and dysfunctions are needing help in the first place. Below you will see a list that includes some of the most common shoulder impairments, both surgical and non-surgical:

  • Adhesive Capsulitis (a.k.a. Frozen Shoulder)
  • Shoulder Impingement
  • Shoulder Rotator Cuff or Other Muscle/Tendon Tear
  • Shoulder Rotator Cuff Repair
  • Shoulder Tendinopathy
  • Total Shoulder Arthroplasty
  • Reverse Total Shoulder Arthroplasty
  • Shoulder Open Reduction Internal Fixation Status Post Fracture
  • Shoulder Dysfunction Status Post Mastectomy with or without Reconstruction

As you can see, there are a multitude of shoulder injuries that can occur. Typically, if a surgery has been involved, it is not uncommon to follow a specific protocol established by your surgeon. It is important to follow these protocols, as they have a specific timeline to allow optimal soft tissue healing, and gradually promote return to full functioning without harming the surgical site. If a shoulder injury is non-surgical and has not resulted from a severe trauma, the rehab progression will normally be based on how you present at your initial evaluation with your physical therapist.

The Importance of Range of Motion

One of the first items a physical therapist will assess during an initial consult is how much range of motion (ROM) is available. It is vital to gain as much functional and pain-free ROM as possible early in the rehab process. ROM exercises are necessary to maintain and promote mobility of the joints and soft tissues. Without this, you will quickly lose tissue flexibility and may develop a contracture.1

There are three primary types of ROM: passive range of motion (PROM), active-assisted range of motion (AAROM), and active range of motion (AROM).1 A pulley will be helpful in promoting AAROM; however, each ROM type has its proper place in the rehab process. Understanding the specifics of each type of ROM can help in understanding the role of a shoulder pulley and how it helps in recovery.

PROM:

PROM is created by an outside force. This may occur via a machine or by a person, such as your physical therapist. The goal is to move throughout an unhindered ROM with very little or no active muscle contraction.1 PROM is appropriate if dealing with an acute or inflamed soft tissue, which normally will occur immediately after an injury or surgery. In this phase of healing, an active motion may compromise or delay tissue healing.1 

AAROM:

AAROM is a form of AROM, but still requires some assist from an outside force.1  This type of ROM is usually elicited if attempting to promote a slightly larger muscle contraction than PROM, but still refraining from initiating a full muscle contraction. Holding a full muscle contraction, such as in AROM, may be due to pain level, need for further tissue healing, or muscle weakness. It allows assistance so the muscle groups being stimulated can be gradually strengthened.1

AROM:

AROM produces a full muscle contraction through the available ROM.1 Now tissues have appropriately healed, and an active contraction is desired. AROM can also be encouraged in the areas above and below an immobilized region, in order to maintain functional movement in the unaffected areas.1

Ultimately, the goals of all types of ROM remain the same:

  • Reduce or prevent pain
  • Promote movement of synovial fluid to provide nutrients for cartilage
  • Promote bone and joint integrity    
  • Prevent contracture formation
  • Increase circulation
  • Promote and sustain soft tissue mobility
  • Increase coordination and motor skills1

Amount of Muscle Activation During ROM

As mentioned above, each ROM type will trigger different amounts of muscle activity. Just how much muscle activity is the ultimate question. Various electromyographical (EMG) studies have been performed showing the levels of muscle activity during ROM, as well as functional activities. These guidelines can be extremely helpful to guide the rehab process.

For example, a study from PM & R: The Journal of injury, function and rehabilitation specifically determined muscle activation levels during PROM, AAROM, and AROM in healthy participants.2 Fine wire electrodes were used in two rotator cuff muscles (supraspinatus and infraspinatus), while surface electrodes were used in the anterior deltoid, upper trapezius, lower trapezius, and serratus anterior muscles. These electrodes recorded activity from the above muscle groups during 12 exercises focused on ROM. Ultimately, PROM was found to create the lowest activity level (<10%) for all muscle groups. AAROM created a small level of muscle activity for supraspinatus and infraspinatus (<10%), but slightly greater than what was created via PROM. AROM, particularly shoulder elevation performed in standing, created the greatest amount of muscle activity (40%). The conclusion of the study implies that most of the exercises used early on in rehab, namely with PROM and AAROM, will use a low maximum voluntary muscle contraction. Even the transition from PROM to AAROM will not create a significant difference in muscle activation; however, because of the significant increase in muscle activity with AROM, those exercises are best used in later rehab phases.2

Consider an alternative study from the Journal of Orthopaedic & Sports Physical Therapy. This study specifically determined the amount of rotator cuff muscle activity with functional tasks compared to ROM performed while in physical therapy.3 Indwelling EMG activity was tested with all four rotator cuff muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. Surface EMG activity was tested in the upper trapezius, biceps, and mid deltoid. Donning and doffing a shirt or sling were found to stimulate the greatest muscle activity in the rotator cuff. For a shirt specifically, supraspinatus and teres minor demonstrated the greatest muscle activity, followed by infraspinatus then subscapularis. For a sling however, the highest muscle activity was shown in infraspinatus, subscapularis, and the biceps. In comparison to the rehab ROM tasks, use of a pulley created increased rotator cuff activation when compared to the pendulum exercise, PROM, or use of a dowel. Furthermore, practice of the pulley in the scapular versus sagittal plane caused increased EMG activity.3 This information is significantly important to know and understand to properly guide progressive muscle activity and ROM both in the rehab setting and functionally at home.

Benefits of Home and Professional Rehab

If you are experiencing any type of shoulder pain (e.g., surgical or non-surgical), it is highly recommended to consult with a rehab specialist. If a surgery has been involved, your surgeon will give specific guidelines for when to begin your rehab journey. A rehab professional with knowledge of rehabilitating shoulder injuries (a physical or occupational therapist) can provide an incredible wealth of information and hands-on assistance that will allow for a smooth recovery. Part of your home program provided by your therapist will always involve a home exercise regimen, which is important to adhere to.

An article in the Singapore Medical Journal discusses the typical treatment options specifically for a frozen shoulder.4 While anti-inflammatories and injections are commonly prescribed by medical practitioners to initially treat painful symptoms, this article highlights how and why physical therapy and a home exercise program should be included in the initial management phase. Physical therapy will provide a direct source of education regarding the shoulder diagnosis, pain relief, and sooner return to an individual’s prior level of function. Anti-inflammatories have even been found to work more effectively for pain relief in conjunction with rehab.4 To say the least, the importance of therapy and your home program cannot be overstated.

As ROM progression is one of the first priorities, this is where an at-home pulley can further move along your recovery. Once it is appropriate to initiate the amount of muscle activity found with AAROM, try to begin self-assisted ROM as soon as able. This will promote controlled and assisted movement, while protecting healing soft tissues.1 It is not uncommon during AAROM performed by an outside force (e.g., your therapist or a machine/object), that you may be nervous to elicit a painful response, and therefore begin muscle guarding. Unfortunately, this guarding can worsen pain and will prevent you from gaining the most optimal ROM. For this reason, self-assisted ROM, such as with pulleys, can be very helpful as you are in control of the movement. Additionally, if you’re trying to intentionally create greater muscle activity, this will usually occur with a tool, such as a pulley, versus manual assist from a therapist or machine.1

Another factor to consider is that not everyone will have access to a rehab professional. This may be due to location or finances and lack of insurance. In cases such as these, a home exercise program is incredibly vital. While the combination of in-person therapy and a home program is preferrable, you can still achieve success with an independent home program; however, your recovery may take a little longer. Normally manual therapy is a primary part of shoulder recovery, but studies have shown that use of pulleys for AAROM show similar results as manual joint mobilizations performed by a therapist in certain conditions, such as frozen shoulder. This indicates that AAROM is an effective method for both increasing ROM and reducing pain levels.5

Adherence to a Home Exercise Program

Adherence to any medical routine is vital for successful results. This concept is no different with rehabilitation. Unfortunately, nonadherence is a major issue most healthcare providers face with their patients. Nonadherence to a rehab home exercise program has been found to be as high as 50%.6 This can have a major impact on both a patient’s success and the healthcare system itself. Nonadherence has been found to have a negative effect on clinical results and creates increased problems on patients and their healthcare providers. These negative results can include the need to prolong the rehab process, can potentially create a negative relationship between the patient and therapist, and reduce overall effectiveness of treatment.6

Possible reasons that may contribute to nonadherence may include a lack of self-efficacy, higher pain levels, and a lack of social support. Increased access to educational resources, such as online videos or websites, and a connection to those going through a similar experience via online forums or social networks, have the potential to increase home program adherence and overall patient motivation.6

One other consideration for nonadherence is a lack of the appropriate tools at home to carryover the results of rehab. While a rehab clinic or facility can supply certain pieces of equipment, such as resistance bands, for home, other tools, such as the pulley system, are not routinely provided. Seeing as the at-home pulley system has been shown to be an effective tool for the overall shoulder rehab process, surgical or non-surgical, a patient having access to equipment like this would likely provide increased encouragement and adherence for follow through with the home exercise program. Increased adherence to the home program will benefit all involved, as the patient will be able to return to their desired functional state more quickly and there will be less of a need for additional medical follow up, as the patient will have recovered more effectively and efficiently.

Prehabilitation

While many rehab measures are geared towards post-operative recovery, the role of prehabilitation is becoming more relevant and increasingly utilized. According to the Arthritis Foundation, orthopedic surgeon, Vonda Wright, MD, has been quoted stating that “Fifty percent of outcome success is due to the surgeon, and the other 50% is due to the patient’s commitment to recovery – starting with prehab.”7 Prehab is essentially physical or occupational therapy participation and preparation prior to a scheduled surgical procedure. Participation in prehab has been found to have many benefits and can even improve post-operative results. According to the Arthritis Foundation, patients with planned joint replacement surgeries who participated in prehab to improve strength, endurance and flexibility for six weeks leading up to their surgery demonstrated a decreased need for inpatient rehab by up to 73%.  Prehab has also shown the possibility of reducing post-operative complications, reducing length of hospital stay, reducing healthcare costs, and improving a patient’s quality of life.7

While the positive effects of prehab are becoming more evident, the prehab process with a rehab professional will also include a home exercise program. As previously mentioned, part of what will initiate greater success at home and ultimately success throughout the entire rehab process is having the appropriate tools and resources for better follow through with the home exercise program.

Case Study

Consider a case study by The Journal of Physical Therapy Science. This study, completed in 2020, focused on a 62-year-old male scheduled for a reverse total shoulder arthroplasty on his right shoulder. The patient proactively initiated physical therapy prehab two months prior to his scheduled surgery. At the initial evaluation, this patient demonstrated significant right shoulder pain, stiffness, and functional deficits due to rotator cuff tears and arthritis. Also evident at the initial consult was that the patient demonstrated poor postural awareness, decreased ROM, and decreased strength. All of these factors negatively impacted functional performance and use of his right upper extremity.8

The patient participated in physical therapy, as well as maintained excellent compliance with his home exercise program, over a one-month period (six total physical therapy treatments). At the last visit, the patient demonstrated significantly reduced pain levels, improved postural awareness, increased ROM and strength. As a result, this patient elected to postpone his scheduled surgery because of his success. At a three-month follow up, the patient had either maintained or improved his results with the previously utilized tests and measures and functional outcome reports.8

Conclusion

The role of a pulley in the rehab process should always be addressed in the clinic and at home. Once a patient has reached an appropriate time frame of tissue healing, and a certain amount of muscle activity is warranted, the pulley is a great tool to aid in recovery. After guidance from a rehab professional as to how to properly use a pulley to progress functional ROM, consider acquiring this tool for your home program. It will allow you to gently advance a greater pain-free range, while also re-training your shoulder musculature. This will allow you to recover more efficiently and move on to the more advanced phases of the rehab process in a timely manner, as well as could even have the potential to either avoid surgery or enhance surgical outcomes if used in the prehab phase. As the positive results from consistent participation with a rehab professional and the home exercise program become more apparent, the patient will feel more motivated to remain compliant, which will subsequently allow for better outcomes and a faster return to the patient’s desired functional status.

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